Australian Government Department of Health and Ageing Medicare Benefits Schedule Book Pathology Services Category 6 Operating from 01 January 2010

P.1.2. Exemptions to Basic Requirements

Prescribed Pathology Services

A prescribed pathology service is a service included in Group P9 of the Pathology Services Table. Group P9 contains 11 services which may be performed by a medical practitioner in his or her own surgery on his or her own patients.

Additionally, benefit is payable only where the service is determined to be necessary by the medical practitioner rendering the service, or is in response to a request by a member of a group of practitioners to which that practitioner belongs (see PO.2 for the definition of a "group of practitioners").
Services Where Request Not Required

A written request is not required for  

(i) a prescribed pathology service rendered by or on behalf of a medical practitioner upon his or her own patients;

2. 
   a pathologist-determinable service. A pathologist-determinable service is a pathology service :
   

1. 
   that is specified rendered by or on behalf of an Approved Pathology Provider for a person who is a patient of that Approved Pathology Provider who has determined that the service is necessary; or
   
2. 
   that is specified in only one of immunohistochemistry items 72846, 72847 or 72848 or immunocytochemistry items 73059, 73060 or 73061 or electronmicroscopy items 72851 or 72852 and is considered necessary by the Approved Pathology Provider as a consequence of information resulting from a pathology service contained in tissue examination items 72813 – 72836, cytology items 73045 – 73051 or tissue examination items 72813 - 72836 respectively.
   

Please note: a written request is required for a service contained in items 72813 to 72836 and items 73045 to 73051.

3. 
   That is specified in one of the antigen detection items 69494, 69495 or 69496 is considered necessary by the specialist pathologist as a consequence of information provided by the requesting practitioner or by the nature or appearance of the specimen or as a consequence of information resulting from a pathology service contained in items 69303, 69306, 69312, 69318, 69321, 69345. Please note: a written request is required for a service contained in items 69303, 69306, 69312, 69318, 69321, 69345 or for a service contained in items 69494, 69495 or 69496.
   
4. 
   That is specified in item 73320, HLA-B27 typing by nucleic acid amplification, and is considered necessary by the specialist pathologist because the results of HLA-B27 typing described in item 71147 are unsatisfactory.
   

Further information on additional pathology tests not covered by a request is provided at PB.3.

P.1.3. Circumstances Where Medicare Benefits Not Attracted

Services Rendered by Disqualified Practitioner

Medicare benefits are not payable for pathology services if at the time the service is rendered, the person, by or on whose behalf the service is rendered, is a person in relation to whom a determination is in force in relation to that class of services. That is, where an Approved Pathology Practitioner has breached an undertaking, and a determination has been made that Medicare benefits should not be paid during a specified period (of up to five years) in respect of specified pathology services rendered by the practitioner.

Note: An Approved Pathology Practitioner may be disqualified for reasons other than a breach of undertaking.
Certain Pathology Tests Do Not Attract Medicare Benefits

Certain tests of public health significance do not qualify for payment of Medicare benefits. Examples of services in this category are:

- examination by animal inoculation;

- Guthrie test for phenylketonuria;

- neonatal screening for hypothyroidism (T4/TSH estimation);

- neonatal screening for Cystic Fibrosis;

- neonatal screening for Galactosemia;

- pathology services used with the intention of monitoring the performance enhancing effects of any substance;

- pathology tests carried out on specimens collected from persons occupationally exposed to sexual transmission of

- disease where the purpose of the collection of specimens is for testing in accordance with conditions determined by the health authority of the State or Territory in which the service is performed.

In addition to the above, certain other tests do not qualify for payment of Medicare benefits. These include:

- cytotoxic food testing;

- pathology services performed for the purposes of control estimation, repeat tests (eg. for confirmation of earlier tests on the same specimen, etc);

- preparation of autogenous vaccines;

- tissue banking and preparation procedures;

- pathology services performed on stillborn babies or cadavers;

- pathology services which are performed routinely in association with the termination of pregnancy without there being any indication for the necessity of the services.
However, benefits will be paid for the following pathology tests:

- item 65060   haemoglobin estimation;

- item 65090   blood grouping ABO and Rh (D antigen);

- item 65096   examination of serum for Rh and other blood group antibodies.

P.2.1. Responsibilities of Treating/Requesting Practitioners

Form of Request
A treating practitioner may request a pathology service either orally or in writing but oral requests must be confirmed in writing within fourteen days from the day when the oral request was made.
Pathology request forms and combined pathology request/offer to assign forms which are prepared by the pathologists and distributed to requesting practitioners must be in accordance with the Medicare Australia approved form (see P.2.2). Written pathology requests from treating practitioners that are not on a form prepared and distributed by a pathologist do not need to be approved. However, all written requests for pathology services should contain the following particulars:
(i) the individual pathology services, or recognised groups of pathology tests to be rendered (see section PQ of these notes for the list of acceptable terms and abbreviations). The description must be sufficient to enable the item in which the service is specified to be identified;

(ii) the date of request;

(iii) the surname, initials of given names, practice address and provider number of the requesting practitioner;

(iv) the patient's name and address;

(v) details of the hospital status of the patient, as follows (for benefit rate assessment). That is, whether the patient was or will be, at the time of the service and when the specimen is obtained:

(a) a private patient in a private hospital, or approved day hospital facility;

(b) a private patient in a recognised hospital;

(c) a public patient in a recognised hospital;

(d) an outpatient of a recognised hospital;

(vi) details of the person to whom the request is directed. A pathology request can be directed to an Approved Pathology Practitioner or an Approved Pathology Authority. If the request is directed to an Approved Pathology Authority, the form must show the full name and address of the Approved Pathology Authority. If the request is directed to an Approved Pathology Practitioner, the form must show the surname, initials or given names and place of practice of the Approved Pathology Practitioner to whom the request is addressed.

Offence Not to Confirm an Oral Request

A requesting practitioner who, without reasonable excuse, does not confirm in writing an oral request within fourteen days of making the oral request is guilty of an offence under the Health Insurance Act 1973 punishable, upon conviction, by a fine not exceeding $1000, and the request is deemed never to have been made.